Patient Satisfaction is Equivalent for Inpatient and Outpatient Minimally-Invasive Adrenalectomy

Abstract

Introduction:

Same-day surgery in the carefully selected patient decreases costs, improves inpatient capacity, and decreases patient exposure to hospital-acquired conditions. Outpatient adrenalectomy has been shown to be safe and effective, but patients’ perspectives have yet to be addressed. This study compares patient satisfaction following inpatient and outpatient adrenalectomy.

Methods:

An institutional database was queried for minimally-invasive adrenalectomies performed from 2017 to 2020. Patients were contacted up to two times to participate in a phone survey consisting of 25 questions modeled after the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS®) assessing preparation for surgery, discharge experience, post-operative course, and overall satisfaction. Statistical analysis was performed using Kruskal Wallis, Wilcoxon-Mann Whitney, and Chi-square tests, as appropriate.

Results:

One hundred five adrenalectomy patients were identified, of which 98 were contacted and 58 responded (59%). Two surgeons contributed patients, with no difference in the percentage of patients in the outpatient group (51.7% vs 62.1%, p=0.423). Outpatient adrenalectomy patients had slightly higher overall experience scores, but this difference was not statistically significant (9.12 ± 1.36 vs 8.93 ± 1.51, p=0.367). Patients undergoing outpatient adrenalectomy were more likely to have their discharge plan discussed pre-operatively (94% vs 62%, p=0.005), but no significant differences were noted between inpatient and outpatient groups regarding preparation for surgery, readiness for discharge, night of surgery experiences, or self-reported pain or complications (p>0.05 for all). Significantly higher overall experience scores were reported by patients counseled about their discharge plan (9.27 vs 7.9, p=0.036), felt prepared for recovery (9.39 vs 5.5, p<0.001), received information about pain control (9.13 vs 7.00, p=0.031), felt prepared at time of discharge (9.33 vs 5.80, p<0.001), and received information about potential complications (9.29 vs 7.00, p=0.001). Although not statistically significant, there was a trend towards outpatients being more likely to choose the same approach if they were to undergo surgery again (97% vs 84%, p=0.081).

Conclusions:

Patient satisfaction following adrenalectomy is significantly associated with patients’ self-reported degree of preparation for surgery and discharge, with no significant difference in patient satisfaction between inpatient and outpatient groups. Patients undergoing outpatient adrenalectomy would be likely to choose the same approach compared to inpatients. Targeted pre-operative counseling can contribute to enhanced patient outcomes for all patients undergoing adrenalectomy.

INTRODUCTION

Developments in minimally-invasive surgery over the past several decades have led to the popularization of several minimally-invasive approaches to adrenalectomy, including laparoscopic transabdominal, robotic transabdominal, and posterior retroperitoneoscopic approaches, and patients undergoing these procedures have been shown to have no difference in safety compared to those undergoing open adrenalectomy.^1–4 Specifically, laparoscopic adrenalectomy has been shown to be associated with decreased post-operative opioid use, hospital length of stay (LOS) and hospital patient charges, along with enabling faster resumption of diet and independent activity compared to open adrenalectomy.^5–6 These benefits have made minimally-invasive adrenalectomy the preferred approach at most institutions.

The same patient benefits of less pain, hospital LOS and cost have been demonstrated in other minimally-invasive procedures, including laparoscopic cholecystectomy and laparoscopic hernia repair. Patients undergoing these procedures have seen a steady transition toward being performed routinely on an outpatient basis because when combined with appropriate patient selection, outpatient minimally-invasive surgery has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Laparoscopic adrenalectomy stands out as a minimally-invasive procedure that has not been widely adopted on a same-day basis despite early literature suggesting that it can be feasible and safe in selected patients and is associated with significant cost savings.^7–10

A study performed by our group plus one other institution demonstrated that outpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates.¹ However, this study did not include an examination of patient satisfaction, a critical component of patient-centered care that provides an opportunity to improve both care quality and long-term compliance with provider recommendations.¹¹ This study aims to retrospectively compare satisfaction between patients undergoing same-day and inpatient-stay minimally-invasive adrenalectomy from a single tertiary academic medical center.

METHODS

An institutional database was queried for all adrenalectomies performed from June 1, 2017, when same-day adrenalectomy was initiated at our institution, through June 30, 2020. Patients met inclusion criteria if they underwent minimally-invasive adrenalectomy via a laparoscopic, retroperitoneoscopic, or robotic approach, were greater than 18 years of age, and were able to participate in a phone survey. Cases involving removal of other organs, bilateral adrenalectomy, and those performed in patients already admitted to the hospital were excluded. Participants were divided into two groups: those who had undergone minimally-invasive adrenalectomy with an inpatient stay of at least one night (inpatient group), and those who had undergone minimally-invasive adrenalectomy as a same-day operation (outpatient group), defined as discharge on the same day as surgery with no overnight hospital stay. All patients were informed that the operation is routinely performed on an outpatient basis and that the ultimate decision for outpatient adrenalectomy would be made on the day of surgery based on intra-operative course, recovery in the post-anesthesia care unit, and the patient’s overall comfort/readiness for discharge. No strict, upfront criteria were defined to make patients ineligible for outpatient adrenalectomy. Participants in both groups were contacted up to three times and asked a series of 21 standardized questions, with the outpatient group also completing 4 additional questions (Supplemental Table 1).

The survey utilized questions from the Communication domain of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Survey (OAS CAHPS®),¹² which has a large body of evidence for its validity, plus additional questions from a previously-published instrument used in an assessment of satisfaction with outpatient lumbar microsurgical discectomy.¹³ These questions assessed patients’ perceptions of several domains, including preparation for surgery, discharge experience, post-operative course, as well as asking them to provide an overall experience satisfaction score on a scale of 1–10. The questions specific to the outpatient group additionally assessed whether they would recommend the outpatient procedure to a friend or colleague, and what their initial thoughts and reactions were to the idea of being discharged on the same day as surgery.

Corresponding to the OAS CAHPS survey, most questions utilized a yes/no response scale (n=15), or a yes, definitely/yes, somewhat/no response scale (n=10). Participants were provided an opportunity to clarify or provide additional information for most questions, and any responses of uncertainty were omitted from the dataset. Statistical analysis was performed using Kruskal Wallis, Wilcoxon-Mann Whitney, Chi-square tests, and multivariable linear regression, as appropriate, with Stata version 16 (StataCorp, College Station, TX). Our institutional review board for human subjects research approved this study prior to its initiation, and all participants provided verbal assent following the reading of an informed consent statement indicating that participation was voluntary, confidential, would not affect their care in any way, and that they could withdraw at any time.

RESULTS

Of the 105 patients that were identified, 98 met inclusion criteria and 58 completed the survey (59%). 35 patients were not able to be contacted, 5 patients indicated that they did not want to participate in the survey and 7 patients were not able to participate due to extenuating circumstances such as hearing loss. No significant differences were identified in demographic characteristics, indications for surgery, and hospital length of stay between survey responders and non-responders. Among participants, 33 comprised the outpatient adrenalectomy group (56.9%), with 25 patients in the inpatient adrenalectomy group (43.1%).

As can be found in our group’s prior study, indications for surgery included nodule/mass, primary hyperaldosteronism, pheochromocytoma, Cushing’s syndrome, and metastasis/concern for metastasis.¹ The average length of stay post-surgery was 13.1 hours for all patients with an average length of 2.5 hours for outpatients and 19.8 hours for inpatients (Table 1). Among the 98 patients meeting inclusion criteria, 30-day readmission rate was 4.1% with all readmissions occurring within the inpatient group (4 vs 0, p=0.045). Additionally, the inpatient group had significantly more complications compared to the outpatient group (3.8% vs 19.6%, p=0.022), but this was not observed when comparing these groups only among survey respondents.

Table 1.

Characteristics of all patients that met inclusion criteria.

	All Patients				Survey Respondents
	All (n=98)	OP (n=52)	IP (n=46)	p-value	All (n=58)	OP (n=33)	IP (n=25)	p-value
Hours discharged post operatively, mean	13.1	2.5	19.8	<.001	12.8	2.8	26	<.001
Readmitted postoperatively	4 (4.1%)	0	4 (8.7%)	0.045	3 (5.2%)	0	3 (12%)	0.08
30-day complication	11 (11.2%)	2 (3.8%)	9 (19.6%)	0.022	7 (12.1%)	2 (6.1%)	5 (20%)	0.22

OP = Outpatient; IP = Inpatient

The non-responder group included 21 outpatients and 19 inpatients, with the outpatient group having a complication rate of 0% and the inpatient group having a complication rate of 19%. Outpatient non-responders had an average length of stay post-surgery of 2.5 hours and inpatients non-responders had a length of stay of 23.5 hours. A comparison of the responder and non-responder groups found no significant difference in outpatient length of stay post-surgery (p=0.609), outpatient complication rate (p=0.527), inpatient length of stay post-surgery (p=0.315), or inpatient complication rate (p=1.000).

In the conducted survey, patients undergoing outpatient adrenalectomy were more likely to have their discharge plan discussed pre-operatively (94% vs 62%, p=0.005), but no significant differences were noted between inpatient and outpatient groups regarding preparation for surgery or readiness for discharge. Regarding post-operative course, there were no significant differences in scores between inpatient and outpatient groups regarding night of surgery experiences generally, or self-reported pain or complications (Table 2). Two surgeons were represented in the institutional database and there no difference in the percentage of their patients in the outpatient group (51.7% vs 62.1%, p=0.423), or mean overall experience score of their patients (9.34 vs 8.52, p=0.13).

Table 2.

Survey Responses of Outpatient and Inpatient Groups

Question	Percent Yes Response		p-Value
	Outpatient	Inpatient
Offered outpatient	94%	62%	0.009
Adequate preoperative information	100%	96%	0.431
Prepared for discharge	91%	92%	0.872
Sleep interrupted	45%	56%	0.630
Post procedure pain	82%	64%	0.125
Post procedure complication	24%	24%	0.983

In the domains of preparation for surgery and discharge experience, significantly higher overall experience scores were reported by patients counseled about their discharge plan (9.27 vs 7.9, p=0.036), felt prepared for recovery (9.39 vs 5.5, p<0.001), received information about pain control (9.13 vs 7.00, p=0.031), felt prepared at time of discharge (9.33 vs 5.80, p<0.001), and received information about potential complications (9.29 vs 7.00, p=0.001). Further, patients that felt that they had received sufficient information post-operatively had significantly higher experience scores (9.15 vs 6.6, p= 0.013) There were no significant differences in ratings for any of these factors between the outpatient and inpatient groups.

Outpatient adrenalectomy patients had slightly higher absolute experience scores, but this difference was not statistically significant (9.12 ± 1.36 vs 8.93 ± 1.51, p=0.367). Patients that agreed that they would choose the same surgical approach if given the option had significantly higher overall experience ratings (p<0.001), as did patients that indicated that they would recommend an outpatient approach to others (p=0.006). Additionally, there was a non-significant trend toward outpatients being more likely to choose the same approach (97% vs 84%, p=0.081). Patients in both groups indicating they would choose the same approach if faced with surgery again were more likely to agree they received adequate information before and after surgery (p=0.001 for both), felt prepared for recovery (p<0.001), received information about treating pain (p=0.001), felt safe at discharge (p=0.037), and prepared for discharge (p<0.001).

A multivariable linear regression model was constructed to control for the relationship between variables. This analysis identified that only the feeling of being prepared for discharge at the time of departure was an independent predictor of overall experience ratings (1.08, 95% CI 0.04 – 2.13, p=0.043), but that inpatient vs outpatient status and surgeon were not.

DISCUSSION

This retrospective analysis of satisfaction data from 58 patients following minimally-invasive adrenalectomy identified that patient satisfaction is significantly associated with patients’ self-reported degree of preparation for surgery and discharge, and that this was not different between inpatient and outpatient groups. These results indicate that, more so than whether a patient spends the night of surgery in the hospital, peri-operative counseling is a singularly important contributor to patient satisfaction. Although satisfaction scores were not significantly higher among the outpatient group compared to their inpatient counterparts, the observed difference in absolute scores could be attributable to multiple factors, including that satisfaction of patients with an inpatient stay may have affected by their reason for admission, that inpatients had unaddressed factors that affected their experience, or that the meticulous care taken to educate patients undergoing same-day discharge early on may have contributed to a positive halo effect. Further studies are needed to determine if these differences would reach statistical significance in a larger study population.

A study comparing inpatient versus outpatient hip and knee arthroplasty with 102 inpatients and 64 outpatients found that outpatients were more satisfied in the areas of nursing staff, pain management, and preparedness for discharge.¹⁴ As consistent with our findings, it has also been demonstrated that patients’ ratings of their discharge instructions and education were positively correlated with overall satisfaction.¹⁵ What these data point to is the need for consistent and high-quality patient education throughout the perioperative period, and particularly about the processes and timing of discharge. Standardized, high-quality patient discharge information and education, regardless of discharge status, may be likely to enhance overall satisfaction scores.

Minimally invasive outpatient adrenalectomy has been shown to be safe and effective. The safety of this procedure has been demonstrated repeatedly for high-volume practitioners such as endocrine surgeons,¹⁶ with a recent study confirming that endocrine surgeons reach the threshold for high-volume adrenal surgery during their fellowship training.¹⁷ The present study also adds to the body of literature indicating that the procedure is associated with high patient satisfaction whether performed on an inpatient or outpatient basis. However, adrenalectomy remains on the Centers for Medicare and Medicaid Services inpatient-only procedure list.¹⁸ As the practice of minimally-invasive adrenalectomy becomes more routine, the “inpatient only” status of this procedure warrants reevaluation.

Although this study presents the largest sample of inpatient and outpatient adrenalectomy patient satisfaction data collected to date, its findings may be limited by a relatively small sample size. Further, the retrospective nature of this study is also associated with specific limitations, including recall and selection bias, as patients were not randomized to outpatient or inpatient surgery. Patient response rate was lower in the inpatient group, which may also contribute to selection bias in this study, but no significant differences were identified in demographic characteristics or clinicopathologic parameters between respondents and non-respondents. While acknowledging these factors, a power calculation was performed a priori to ensure sufficient power to detect a difference of 0.5 in experience score as significant, and findings from this study are a first step to fill the void of understanding patient experiences related to outpatient adrenalectomy since prior work has already demonstrated the procedure can be performed safely.¹ The results of our study are also consistent with other studies demonstrating that greater care taken in patient discharge education is correlated with higher satisfaction scores.¹⁵

While this study provides an important source of data for surgeons and other stakeholders to consider in determining whether minimally-invasive adrenalectomy is appropriate for the outpatient setting, more data regarding the cost differential between inpatient and outpatient adrenalectomy, impact on increasing bed availability, and impact on decreasing patient exposure to hospital-acquired conditions are needed. Additionally, a prospective examination of patient satisfaction following adrenalectomy is needed and could also help to determine whether differences in patient satisfaction occur based on the underlying disease process.

CONCLUSION

In conclusion, our data show that patient satisfaction is equivalent between inpatient and outpatient minimally-invasive adrenalectomy groups. Patient satisfaction was found to be significantly related to preparation for surgery and discharge, with patients that felt they were counseled about their discharge plan, felt prepared for recovery, received information about pain control, felt prepared at time of discharge, and received information about potential complications having statistically significantly higher experience scores than patients that felt they did not.